A review of the ways in which healthcare professionals can be helped to involve their patients in the healthcare decision making process

When there are several treatments possible, healthcare professionals can involve patients in the process of making decisions about their care so that the patients can choose care that meets their needs and reflects what is important to them. We call this 'shared decision making'. Although the results are better when patients are involved, healthcare professionals often do not involve their patients in these decisions. We wanted to know more about what can be done to encourage healthcare professionals to share decision making with their patients. In our review we identified 39 studies that tested what activities work in helping healthcare professionals involve their patients more in the decision-making process. We learned that any such activity was better than none, and that activities for healthcare professionals and patients together worked somewhat better than activities just for patients or just for healthcare professionals. However, given the small number of studies and the differences across the studies, it was difficult to know which activities worked best. This review suggested ways to better evaluate how much healthcare professionals involve patients in healthcare decisions so that we can understand this process better in the future.

Authors' conclusions: 

It is uncertain whether interventions to improve adoption of SDM are effective given the low quality of the evidence. However, any intervention that actively targets patients, healthcare professionals, or both, is better than none. Also, interventions targeting patients and healthcare professionals together show more promise than those targeting only one or the other.

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Background: 

Shared decision making (SDM) can reduce overuse of options not associated with benefits for all and respects patient rights, but has not yet been widely adopted in practice.

Objectives: 

To determine the effectiveness of interventions to improve healthcare professionals’ adoption of SDM.

Search strategy: 

For this update we searched for primary studies in The Cochrane Library, MEDLINE, EMBASE, CINAHL, the Cochrane Effective Practice and Organisation of Care (EPOC) Specialsied Register and PsycINFO for the period March 2009 to August 2012. We searched the Clinical Trials.gov registry and the proceedings of the International Shared Decision Making Conference. We scanned the bibliographies of relevant papers and studies. We contacted experts in the field to identify papers published after August 2012.

Selection criteria: 

Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies evaluating interventions to improve healthcare professionals' adoption of SDM where the primary outcomes were evaluated using observer-based outcome measures (OBOM) or patient-reported outcome measures (PROM).

Data collection and analysis: 

The three overall categories of intervention were: interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. Studies in each category were compared to studies in the same category, to studies in the other two categories, and to usual care, resulting in nine comparison groups. Statistical analysis considered categorical and continuous primary outcomes separately. We calculated the median of the standardized mean difference (SMD), or risk difference, and range of effect across studies and categories of intervention. We assessed risk of bias.

Main results: 

Thirty-nine studies were included, 38 randomised and one non-randomised controlled trial. Categorical measures did not show any effect for any of the interventions. In OBOM studies, interventions targeting both patients and healthcare professionals had a positive effect compared to usual care (SMD of 2.83) and compared to interventions targeting patients alone (SMD of 1.42). Studies comparing interventions targeting patients with other interventions targeting patients had a positive effect, as did studies comparing interventions targeting healthcare professionals with usual care (SDM of 1.13 and 1.08 respectively). In PROM studies, only three comparisons showed any effect, patient compared to usual care (SMD of 0.21), patient compared to another patient (SDM of 0.29) and healthcare professional compared to another healthcare professional (SDM of 0.20). For all comparisons, interpretation of the results needs to consider the small number of studies, the heterogeneity, and some methodological issues. Overall quality of the evidence for the outcomes, assessed with the GRADE tool, ranged from low to very low.

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